A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Assess the client's ability to communicate with the other staff members.

Arrange a meeting with the family to discuss the client's situation.

Administer the client's antidepressant medication as prescribed.

Establish a structured routine for the client to follow.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing communication ability is important but secondary to establishing a structured routine to address the client's immediate needs.

Choice B reason: Arranging a meeting with the family can provide support but is not the first priority in managing the client's depressive symptoms.

Choice C reason: Administering antidepressant medication is essential but must be part of an overall structured plan.

Choice D reason: Establishing a structured routine helps provide stability, encourages participation in daily activities, and addresses the client's refusal to eat and bathe.

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Correct Answer is D

Explanation

Choice A reason: Nausea and headache are common side effects of many medications, including linezolid, but they are not the most critical findings that need immediate reporting to the healthcare provider.

Choice B reason: Increased fatigue is a concerning symptom but may be related to the underlying infection or other factors. It is important to monitor but is not the most urgent finding in this context.

Choice C reason: Yellow-tinged sputum may indicate an ongoing infection, but it is not uncommon in cases of pneumonia. It should be monitored but does not require immediate reporting unless there are other concerning symptoms.

Choice D reason: Watery diarrhea is the most important finding to report because linezolid can cause Clostridioides difficile-associated diarrhea (CDAD), a potentially serious condition. Early detection and treatment are crucial to prevent complications.

A. Observe the appearance of the client's urine. B. Measure the girth of the client's lower abdomen. C. Auscultate an area six inches below the umbilicus. D. Palpate the area above the pubic symphysis.

Correct Answer is D

Explanation

Choice A reason: Observing the appearance of urine can provide information but is not the most direct assessment for urinary retention.

Choice B reason: Measuring the girth of the lower abdomen is not a specific assessment for urinary retention.

Choice C reason: Auscultation is not a reliable method for assessing urinary retention.

Choice D reason: Palpating above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

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A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is D

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is D

Explanation

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